What is the A&E standard and how is the NHS performing?
Performance against the four-hour standard
So far in 2016/17 the NHS has not met the four-hour standard, failing it every month of the year. The standard has now not been met for the past 17 months.
In quarter 3 2016/17 (October to December 2016), the proportion of patients spending longer than four hours in A&E reached its highest level for this time of year in more than a decade. Only 4 out of 139 hospitals with major type 1 A&E departments (see box, below, for details) met the standard. It is now certain that 2016/17 will be the third year running that the NHS will miss the standard across the year as a whole.
Figure 1 shows A&E waiting time performance since 2003/4. From 2005 to 2010 the proportion of patients spending more than four hours in A&E hovered around 2 per cent – in line with the 98 per cent target introduced in 2000 and first met for a full year in 2005.
However, since April 2011, when the coalition government relaxed the target to 95 per cent, the proportion of patients waiting longer than four hours has increased.
Figure 1 also shows how performance against the four-hour standard tends to improve in the summer months.
However, while performance recovered in the summer of 2016/17, it still breached the standard.
Has the number of people going to A&E increased?
For many years, the number of people attending A&E remained unchanged at around 14 million a year.
In 2003/4, the number of attendances jumped – by nearly 18 per cent – to 16.5 million. This reflects the decision around this time to incorporate data from walk-in centres and minor injuries units (type 3 units) in the figures. These units aimed to improve patients’ access to primary care, be more responsive to patients’ busy lifestyles, and offer patients more choice (Monitor 2014).
Since 2003/4, the overall number of attendances has increased significantly, rising to 22.9 million in 2015/16, an increase of more than 39 per cent. Until 2012/13, attendances in type 3 units accounted for the vast majority of this increase, with attendances in type 1 units increasing at a much lower rate.
More recently attendances at type 1 and 3 units have increased at a similar rate: between 2013/14 and 2015/16 there were increases of 5 and 6 per cent in attendances at type 1 and 3 units respectively (NHS England 2017).
While attendances have increased and performance has worsened over the past few years, attendances at A&E departments is not the main factor affecting performance. The seasonal trend in attendances supports this: A&E attendances tend to be higher in the summer and lower in the winter when performance tends to be worse. For example, data for 2016/17, show June and July were busier months for attendances with 65,259 and 67,032 per day than November (63,562) and December (62,696). Yet performance against the four-hour standard was worse in the winter.
There are various factors driving this, in particular that during the winter months there is an increase in the proportion of older people attending and in the proportion of people who need to be admitted to a hospital bed as an emergency. This was highlighted in our March 2017 quarterly monitoring report. 80 per cent of NHS trust finance directors responding to our survey identified increasing numbers of patients with severe illnesses and complex health conditions as one the key factors behind the rising pressures on A&E departments (2016/17).
Is the pressure on A&E a result of people going to A&E when they should go somewhere else?
Around 11 per cent of people who attend A&E are discharged without requiring treatment, and a further 38 per cent receive guidance or advice only (NHS Digital 2017). This does not mean that all these people are attending A&E unnecessarily or could be cared for elsewhere. For example, someone who leaves A&E without being admitted to a hospital bed may well have attended appropriately because they required treatment or assessment that only A&E could provide.
Three of the claims put forward for why people go to A&E unnecessarily are examined below.
Lack of access to GP appointments
It has been suggested that more people are attending A&E because they can’t get appointments with their GP. It is difficult to pin down accurately how many people this might apply to.
However, the latest results from the GP Patient Survey (July 2016) show that 85 per cent of people were able to get an appointment to see or speak to someone at their GP practice, down from 88 per cent in 2011. Of those who couldn’t get an appointment or who were offered an inconvenient appointment (11 per cent), around 4 per cent reported going to A&E instead.
We know that being able to obtain timely appointments is a key concern for people accessing GP services. However, the data from the GP Patient Survey suggests that while there has been a slight reduction in people’s ability to access their GP, there has not been a significant deterioration.
Access to out-of-hours care and care out of hours
It has been suggested that removing responsibility for out-of-hours care from GPs (as part of contractual changes in 2004) led to an increase in A&E attendances. However, there is no evidence to support this.
Most people go to A&E on weekdays between 9am and 5pm, when GP surgeries are open. However, people are clearly uncertain about how to access care when their GP surgery is closed (out-of-hours care) – results from the GP Patient Survey in July 2015 found that only 56 per cent of people said they knew who to contact out of hours. While this is higher than 2014, it is lower than in previous years.
Access to other types of care out of hours (for example, district nursing care) is also important in keeping people out of hospital. We know that the number of district nurses employed by the NHS has decreased by about 41 per cent in the past six years and that district nursing services are under increasing pressure.
Confusion among patients about where to go
The Keogh review into the urgent and emergency care system expressed concerns that the fragmented provision of services makes the system confusing for the public. In response to these concerns, the NHS five year forward view committed to doing ‘far better at organising and simplifying the system’, with the aim of helping patients to ‘get the right care, at the right time, in the right place’ by making more appropriate use of primary care, community mental health teams, ambulance services and community pharmacies.
To support this, NHS England has been undertaking a review of urgent and emergency care. Eight of the vanguards set up to explore new models of care have been pioneering new approaches to delivering urgent and emergency care services, and many of the proposals laid out in sustainability and transformation plans aim to provide better support in the community to alleviate pressure on urgent and emergency care.
How is A&E performance affected by pressures within hospitals?
Are more patients being admitted to hospital from A&E?
Evidence suggests that more people are being admitted to hospital from A&E. Compared to 2011/12, in 2015/16 there were an additional 481,295 hospital admissions from A&E departments in England; a growth of 13 per cent over this period.
Admissions from A&E in the first three quarters of 2016/17 are up by more than 3 per cent compared to 2015/16. This is the equivalent of more than 13,160 additional people a month.
As the number of people admitted from A&E into hospital wards has increased, so have waiting times. This is because people waiting for admission to hospital tend to wait longer in A&E than people who can be treated in A&E or who are discharged without treatment (Blunt 2014).
As more people wait in A&E departments for admission to a bed in hospital, there is an increasing risk that A&E staff have to be diverted to looking after them and that the A&E department simply runs out of space. Should this happen then all patients may need to wait including those who do not need a bed. Where this happens A&E performance against the four-hour standard can worsen very sharply.
How is performance affected by bed-occupancy rates?
High bed-occupancy rates are often associated with worsening A&E performance. In 2016/17, most hospitals are operating at bed-occupancy rates above 85 per cent – the level at which the Department of Health suggests hospitals will struggle to deal with increasing demand for emergency admissions.
Weekly data from NHS England covering winter (December 2016 to February 2017) shows that over this period the national bed-occupancy rate has been closer to 95 per cent. The Royal College of Emergency Medicine has commented that this level of bed occupancy is ‘unsafe’.
In the third quarter of 2016/17, the number of people who waited in A&E departments for admission to a hospital bed (often described as ‘trolley waits’) for more than four hours after the decision to admit them was 15 per cent, or more than 164,565 people. Furthermore, the year-to-date figures for 2016/17 show an additional 151,973 people waiting more than four hours compared to 2015/16 (see Figure 4).
There has been a particularly sharp rise in the number of patients waiting more than 12 hours from decision to admit to admission. In the third quarter of 2016/17 there were 1,257 such patients compared to just 116 in the same quarter in 2015/16.
Are delays in discharging patients from hospital having an impact?
Delays in discharging patients (known as ‘delayed transfers of care’) are one of the factors that drives up bed-occupancy rates, preventing beds being freed up for those who need to be admitted, and adding to pressures on A&E departments.
The number of delayed transfers of care was relatively stable up until the start of 2014/15 but since then the total number of delayed days has increased by 68 per cent and in quarter 3 2016/17 reached its highest level since 2007. There has been a particularly steep increase this year, with delayed days rising 16 per cent (equivalent to 27,600 extra delayed days) between April and December 2016 (Figure 5).
While the majority of delayed transfers can be attributed to delays within the NHS (58 per cent so far in 2016/17), the proportion attributable to social care has risen recently (from 26 per cent at the end of 2014/15 to 34 per cent in 2016/17). This reflects pressures faced by local councils, which have seen significant cuts to their budgets in recent years.
Though these are the official figures released by NHS England, there have been questions raised as to how well the data captures all delayed transfers of care. The Carter review, National Audit Office and the Nuffield Trust have all suggested the scale of the problem could be much worse than reported in the official figures, with the Nuffield Trust recently suggesting that the number of delays could be up to three times higher than reported by NHS England.
Are A&E pressures due to staff shortages?
A&E departments have faced difficulties in recruiting and retaining staff.
Since 2013, Health Education England and the Royal College of Emergency Medicine have been working together to address workforce shortages in emergency medicine, with a focus on encouraging more medical students to choose emergency medicine as a career. Information from Health Education England suggests that the actions taken so far have had a positive impact, resulting in 98 per cent of training posts being filled.
However, staffing issues remain a significant concern. The Royal College of Emergency Medicine reports that, while recruitment into emergency medicine is now high with most first-year emergency medical training posts being occupied, problems with retention mean it has the greatest attrition rate of any medical specialty, with almost 50 per cent of registrar doctors in their third and fourth years of training resigning. This is of particular concern given the direct contribution these staff make to the delivery of care, and their position as the emergency medicine consultants of the future. While Monitor’s recent analysis (2015) concluded that this did not contribute to the longer waits experienced in 2014/15, most A&E departments are working at a very high level of activity, and there is a limit to the workload staff can undertake without having negative consequences on morale, recruitment and retention, performance and/or patient safety.
A&E waiting times have been increasing over time, with figures for quarter 3 2016/17 (October to December 2016) showing that the proportion of people waiting longer than four hours has reached its highest level in more than a decade. Furthermore, in 2016/17 the NHS is certain to miss the standard for the third year running.
The causes of the problems in A&E, and the solutions to address them, are complex. It is often assumed that performance against the four-hour standard has deteriorated due to an increase in attendances, including by some people who could be better treated elsewhere. However, for many hospitals this is not the primary factor impacting on waiting times. A&E is in constant interaction with other hospital departments (for example, to request diagnostic tests and/or to transfer patients to beds in other parts of the hospital). A&E performance is therefore dependent on processes and capacity in other hospital departments, as well as other parts of the health and care system.
The number of people needing to be admitted from A&E into a hospital bed has increased over time, with rates tending to be highest in the winter. This is particularly a problem in hospitals when the bed-occupancy rate is already high as there are no free beds to admit these patients to. While there are a number of factors driving bed-occupancy rates up, delays in discharging patients from hospital and back into their homes or another more appropriate setting (such as social care) are a particular concern.
A&E is often described as the barometer of the NHS. The significant decline in performance in recent years is not due to a single cause – rather it is the result of a combination of factors that reflect the huge pressures on the health and care system.
It saddens me that many of Australian AE training posts are filled by UK graduates. It also saddens me that there are nearly 50% AE middle grades who are non-trainee posts. Traditionally these are filled by non-EU doctors from Indian and African countries. With the immigration changes these doctors have stopped coming to UK.
While we bust the myths let us also see what is the solution for acute shortage of AE doctors, why our trainees are happy to go to Australia but don't want to do their training in UK and let us learn lessons.
We owe it to our patients and also for our staff. If not quality will drop, cost will increase and both patients and staff will suffer.
I am very sad and also somewhat resentful that doctors are going to Australia.
I am visiting my daughter in Melbourne very soon having been their for three and a half months in 2011.
I was surprised to discover how much must be spent on admin in the Australian system.As a patient with Medicare I had to either pay the total amount and then claim a large percentage back via a Medicare office or fill in many forms or or if they bulk billed then I had to pay the percentage required at the surgery.
One young Australian said he would not take his children to A@E in Melbourne as there would be too much blood??
WE do not hear of the problems in otherrcountries. I have a relation in Vancouver and she had to wait for three days on a trolley in a corridor as they did not have a bed to admit her.
I intend doing some research whilst I am in Australia to find out just exactly how it works.
I wish you all the very best.PS I was admitted to hospital as an emergency ,spent four days there and received surgery eight weeks later. Excellent all round
Much of what is described in this paper is common sense when looking at the impact of policy decisions, investment, geographical pressures, training and recruitment issues and inescapable demographic changes and pressures.
My experience of working in primary, acute and ambulance services at a senior level and at a more remote strategic level tells me that the vast majority of all staff go to work and do a great job with what they have and that there are a great many who are innovative and creative.
The simple fact is that this as your paper highlights a complex area with an incredible number of variables.
It is important to be realistic and honest about what is not only affordable but what is achievable taking into account all the available resources.
Well done again. Keep up the great work - busting the myths and highlighting the issues.
The 'front door' issues make the headlines, but there are untold triumphs and issues lurking beneath that do not get the political and press coverage.
We have an opportunity as clinicians to work with all stakeholders at trust and strategic level to address these issues, with the patient at the centre of the whole scenario - the QIPP savings will follow!
I too enjoy reading the Kings Fund's measured take, on what can be at times a visceral discussion about the future of the NHS, inevitably tarnished with whatever political hue one would wish - a nessecary evil in a system borne by politicians.
We have taken the number used in the data sheet that accompanies the HSCIC report that says: 39% of patients were discharged with no follow-up required. So they could have consumed lots of activity before they were discharged, but with no further treatment required.
But the Focus on A&E report says that, for first A&E treatment, 34.4% of patients received guidance/advice only. So perhaps the true number of patients receiving no treatment is somewhere between the two.
I do think however that we need to be careful about how we class 'guidance only'. Though it is likely that this advice could be given in other healthcare settings, we shouldn't discount its value to patients who felt they needed to see a healthcare professional at short notice.
We have private and public ED's however it is common for the more electronically advanced ED's to charge overseas visitors $400 for an attendance and the you would be eligible to get some of that back from Medicare and the rest from a private insurer ( if you have taken out that level of travel insurance before you travel). Those ED's not so well resourced would likely charge the Medicare rebate only. However Australain health care is based on user pays- we pay for scripts, always GP visits, unless you go you a bulk billing clinic. This is the way it works.
There is no NHS philosophy here for those who can pay and if you are fortunate enough to be able to afford to visit Oz -you pay.
If you have a life threatening illness all bets are off and any ED will ignore all of the above and care for you- even top private ED's would not chase the dollar - if you needed heart surgery after a heart attack they would get on with it and suck it up. This is not infrequent.
TAC - transport accident commission would cover all costs if you are injured on our roads
WC - work cover would cover all costs if you got injured at work
DvA - would cover all costs if ever you out your life on the line for fellow countryman
It's different to the UK but it's not a bad system.
Do not travel and expect fish and chips- unfair. We would grill the fish and have salad and you would feel healthier afterwards.
Enjoy Melbourne- my family have enjoyed my deflection to Oz 25 years ago and on their visits to Oz have needed to utilise the services occasionally and loved it -
Advice. IF YOU PICK UP A MEDICARE CARD FROM A MEDICARE OFFICE AS SOON AS YOU ARRIVE IN THE COUNTRY- to which you are entitled - IT IS LIKELY YOU WILL BE CHARGED NOTHING IF YOU ARE SICK ENOUGH TO NEED ED. You will need to pay a copayment at the GP as everyone does. Unless you go to a bulk billing clinic.
As to why the registrars are coming- look at the case mix and skill base they get here. The days of Oz coming to practice on the POHM's is over. POHm's come here because the training model for ACEM is different and the lifestyle and attitude is wonderful for anyone.
Don't moan that they come- find out what we offer and take it back to UK
The reverse is true. A number of representatives from UK hospitals and government agencies have been recruiting here for UK roles. The money is better in the UK and the bureaucracy problem is less.
The issues we have are globally universal:
Trauma doctors and experienced nurses are in short supply.
Growth in aged care health is growing very quickly
Trolley block is being addressed to avoid ambos being stuck at emergency departments waiting for a A&E bed.
Whats new? Every country has these problems. Doctors and nurses in Australia are paid roughly the same as in the UK if you analyse the higher living costs in Australia and purchasing power.
Relieves the burden on NHS Administrators and Nursing staff
Releases them to focus on caring for patients
Pays for itself quickly and then saves money
Patients love it
Directs patients to the most appropriate health provider
Is already being used by an A&E department in England for 2 years
AND YET WHEN THIS IS INTIMATED TO NHS ENGLAND THEY DON'T BELIEVE THE EVIDENCE BASED STATISTIC ABOUT THE BENEFITS - BECAUSE IT IS "TOO GOOD TO BE BELIEVED" !!!!
You write, "Nearly 40 per cent of patients who attend A&E are discharged without requiring treatment. This does not mean that all these patients are attending A&E unnecessarily or could be cared for elsewhere." What does that mean? Is the A&E designed for people to just stroll in and waste queue time and causing nothing to the system? How is healthcare delivered in the UK- what are the processes?
According to the Foundation trust network, there are systemic problems affecting the NHS see for example http://www.nhsconfed.org/news/2015/01/a-e-performance-indicative-of-intense-pressures-across-system
The Foundation Trust Network also presented problems affecting the NHS and the A&E here http://www.publications.parliament.uk/pa/cm201314/cmselect/cmhealth/171/171vw31.htm#footnote_1
Besides there are other studies that have shown that access to GPs reduce the amount of “unwanted” A&E attendance. See for example
• Inappropriate attendance in A&E by Wise (Wise, 1997)
• Inappropriate attendance in A&E (Murphy, 1998)
• An evaluation of the reasons why patients attend a hospital Emergency Department (Land and Meredith, 2013)
• Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study (Cowling et al., 2013)
• And many more studies
Are there problems within the A&E and GPs operations and within the process of healthcare delivery in the UK? Looking at the data and reports, I feel that there is. What do think? If you see only myths, what are the real problems them or is it that they don’t exist?
Cowling, T.E., Cecil, E.V., Soljak, M.A., Lee, J.T., Millett, C., Majeed, A., Wachter, R.M. and Harris, M.J. (2013) Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study. PloS One, 8 (6), 1-6.
Land, L. and Meredith, N. (2013) An evaluation of the reasons why patients attend a hospital Emergency Department. International Emergency Nursing, 21 (1), 35-41.
Murphy, A.W. (1998) 'Inappropriate'attenders at accident and emergency departments I: definition, incidence and reasons for attendance. Family Practice, 15 (1), 23-32.
Wise, M. (1997) Inappropriate attendance in accident and emergency. Accident and Emergency Nursing, 5 (2), 102-106.
We have a dedicated ward (in a separate building) for physiotherapy but it is nowhere near large enough. If it was larger, or if there were more places like it, then the flow of patients out of acute wards could be increased. The problem all comes down to money. If halfway wards for PT and OT were built than less could be spent elsewhere.
What we really need is more options for patients so they can be discharged from acute wards. More dedicated rehabilitation facilities for medically fit patients, more carers in the community, better integration with nursing homes so it is quick and easy for families to choose a home and for nursing assessments to be made, and a better supply of equipment so patients can receive care at home if they wish.
1. How much has the non-medical advice at 111 contributed?
2. You need to look for better evidence of patients being sicker eg multiple diagnoses etc.
I tried to answer some of the questions some tn years ago and so went through A&E documents, compiled a list of common presenting symptoms in GP surgery, OOH NHS Direct clinic, Private healthcare in Harley Street, RAF and Island (Isle of white) before I developing my tool called MAYA. (Medical Advice You Access). People who are compiling statistics in A&E and clinic know the documents are not clear and so the statistics are often wrong.
When I did this work, I have seen doctors diagnosis documented as snuffles, cold, flu, chesty, vomit, URTI, LRTI, UTI and all sorts of rubbish. I have also identified numerous mistakes that NHS was not happy to hear. I raised concern, informed GMC, BMA, NMC and Royal Colleges but none wanted to hear what I had to say.
The kind of work I did was not retrospective and so is accurate and likely to be helpful to resolve the crisis. Only way you can know what is going on and how to solve this problem is to start similar study and not use old data. If you want to help, why not ask doctors (clinicians) like me, who worked as staff doctors or registrars and not professors or consultants. I think Peter Gill has highlighted the problem well and Colin Powell has also suggested changes (Arch Dis Child 2013).
I am sure you will know hear more about this when I appear in the high court because I have taken legal action against NHS for harassing me for doing my duty to protect fellow human.
The reason I am not releasing in App store is because this tool will make doctors loose control. If I don't succeed in doctors accepting my work and using to help them selves and their patients, then the I am planning to publish a book and sharing my apps.
Please note I have used the same logic approach to differentiate minor from serious illness for 30 years when I worked in major NHS hospitals. Please note I am still register and licensed to work as a doctor and GP in UK but am too scared to return to work in the NHS.
Thank you for sharing the information.
The last thing we need is scaremongering and, in this election year, we'll get enough of that from politicians without think tanks joining in.
Effeciencies are needed in every system but in an emergency pathway they need to be looked at by experts within the field as an entire pathway issue with ideas, suggestions and clear next steps. Am not suggesting papers here - just requesting for clearly thought through suggestions. No am not teaching a 'granny how to suck eggs' but how when a group is battling staffing issues, flow issues resulting in performance issues, change fatigue and simple exhaustion how can they see clearly and those that are not in the system can they really comment on the system??
Elderly leave with no idea on who to contact especially at weekends .
To leave a 77 year old Man to look after his74 year old wife who is in pain and inconinant where he had to nurse her 24 hours day and night so that he was at his wits end to know what to do shows how the systems and billions of pounds given are not reaching the front line.
You haven't burst the singular and most important myth. The mainstream media refers constantly to waiting times being longer and more and more people attending A&E. The government have spent many hundreds of thousands of pounds putting the message across that we require 24/7 care deliverable via A&E implying that Doctors and emergency staff are failing to pull their weight-This is not only wrong, it's an out and out lie. There's only one reason that queues are getting longer and that's because over 70 A&E departments are closing or have been closed exposing many UK residents. It's happening by stealth and as an independent charity you have let down your subscribers by not exposing the truth. A disappointing read that really could have exposed the PFI reality which is breaking the NHS!
Community care and social care is mostly inadequate.
CCG's have very little insight into the services they commission.
The four hour target is widely manipulated and not collated by trusts as per DOH guidance.
NHS 111 is variable in quality, dependent on which company runs the contract for an area.
A&E nursing is a dying skill, now predominately occupied by pole climbing sycophants more worried about targets than emergency presentations.
It only leaves me to think that politicians of all colours are eager to sell as much of the NHS off to their rich chums, using unsustainability as the reason.
Currently working as part of a 'front door' team - I find this a great read. Currently involved with a project looking at integration across primary secondary and tertiary servives as part of Older Persons Fellowship Kings College - this gives great evidence to support this
1. If graphs of the trends in type I attendances were shown separately it would better reflect the detriorating situation.
2. The figures fly in the face of plans to dramatically reduce the level off attendances by the development of out of Hospital services.
3. The proportion of resources spent in A&e remains very small as a proportion of total. The refusal to match demand with resources seems perverse.
4. The shortages in junior and trained medical staff has been a deliberate policy to justify rationalisation.
5. little mention is made of the problems in nursing homes, social care and housing and their contribution to the problem.
The target is completely achievable and when where it is achieved you'll reduced length of stay as patient